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Old 08-14-2019, 07:38 PM
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Health Insurers and Step Therapy


In this thread, Ann Hedonia states:
Quote:
Originally Posted by Ann Hedonia View Post
...For example, many insurance companies require that patients try a 30 day course of an older cheaper drug before they will pay for an ultra-expensive version that is virtually identical except for a few insignificant molecular tweaks. Now I think this is a perfectly reasonable policy in most cases. And I bet that any patient forced to make a rational economic decision between a drug that costs $30 a month and a drug that costs $3000 a month would agree to that condition if they were paying the bill themselves.
This is referred to as "step therapy," and like many issues, it's more complicated than this. For starters, drug pricing is arbitrary and set by what the market will bear. Why does one drug cost $30 a month and another drug cost $3000 a month, anyway? It usually has nothing to do with the actual cost to develop and produce the drug by the manufacturer, or how long it has been on the market, and everything to do with what the pharmaceutical companies can get away with charging for it.

But back to step therapy. Insurers are increasingly using it to control costs, while patient advocacy groups and the pharmaceutical industry are generally against it.

The Alliance for Patient Access (AfPA), which is a supposedly a patient advocacy group, but is criticized for its ties to the pharmaceutical industry states:

Quote:
Originally Posted by AfPA
To get the medicine prescribed by their health care provider, patients must first prove that older, less expensive or insurer-preferred alternatives don’t work. That’s the crux of step therapy, or “fail first.”

In some cases, step therapy makes sense. A logical progression of treatment options may represent best practice for certain diseases or reflect the wisdom of clinical guidelines.

In other cases, step therapy can be excessive, arbitrary and even damaging to patients’ health. Insurers may use step therapy as a deliberate access hurdle meant to protect their own profits.

Doing so hurts patients, whose condition may worsen or who may suffer unnecessarily in the process of failing insurer-preferred treatments. It also undermines the relationship between the physician and patient, to whom treatment decisions rightfully belong.
Exerpted from here. More info here, including this graphic.

I've now run into this several times in the last year or so, and I have a good health insurance plan through my employer. In one case, my insurer told me that my asthma medication that I've been using for a decade was being dropped from the formulary. I was forced to switch to a different medication, which failed to control my asthma symptoms, and then another. After two failures, which took many, many months and numerous doctor visits, I was able to get my doctor to write a request to have my original medication prescribed again. About a year after my original medication was dropped, I was finally back on my original medication...but my airway is still so inflamed that I haven't seen much improvement yet. My exercise program has gone to shit due to the resumption of asthma symptoms, and I now feel a lot less healthy than I did a year ago. The worst part is that my preferred medication is actually cheaper than the other two drugs the insurance company insisted I try. The only reason I can tell that my medication was dropped was because the manufacturers of the other medications were able to work out a deal with my insurer.

In another case, I got a bad case of poison ivy. I went in to the urgent care clinic to get something stronger than OTC hydrocortisone and Caladryl, and walked out with a prescription for generic Westcort, which has been on the market for years. When I got to the pharmacy, they wouldn't fill the prescription, because the urgent care doctor was somehow supposed to know that I was required to try two other preferred medications first. So with the urgent care clinic closed for the weekend, I was forced to either pay for the medication myself, delay treatment, or go into an ER and be seen by another doctor. Again, I later found out that both of the preferred medications were comparable in cost to generic Westcort, so I don't see what is being gained here other than a sneaky way for my insurer to avoid paying for my prescription.

The bottom line is that the so-called step therapy, while marketed as a way to control costs, often ends up either denying or delaying care to patients, or forces patients off of long-term drug therapy. Also, while the underlying premise is that similar drugs are basically interchangeable, this is rarely the case, because not all drugs work the same way in different people, and this includes efficacy as well as side effects.
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Old 08-15-2019, 01:49 AM
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Originally Posted by robby View Post
Quote:
Originally Posted by AfPA
To get the medicine prescribed by their health care provider, patients must first prove that older, less expensive or insurer-preferred alternatives don’t work.
This is misleading. Nobody is preventing doctors from prescribing nonformulary medicine without first exhausting formulary alternatives. It is your insurance company which refuses to pay for the medicine, therefore the pharmacy refuses to dispense. If you are willing to pay for the medicine, you can call your doctor and ask them to prescribe the nonformulary medicine. The doctor may refuse on medical grounds, though - they don't have to (and shouldn't) prescribe anything that isn't medically justified.

Quote:
Originally Posted by robby View Post
In one case, my insurer told me that my asthma medication that I've been using for a decade was being dropped from the formulary. I was forced to switch to a different medication, which failed to control my asthma symptoms, and then another. After two failures, which took many, many months and numerous doctor visits, I was able to get my doctor to write a request to have my original medication prescribed again. About a year after my original medication was dropped, I was finally back on my original medication...but my airway is still so inflamed that I haven't seen much improvement yet. My exercise program has gone to shit due to the resumption of asthma symptoms, and I now feel a lot less healthy than I did a year ago. The worst part is that my preferred medication is actually cheaper than the other two drugs the insurance company insisted I try. The only reason I can tell that my medication was dropped was because the manufacturers of the other medications were able to work out a deal with my insurer.
I think Unitedhealthcare switched bronchiodilators twice in two years for some of their plans. Forced non-medical formulary switching is the dumbest thing, and it hurts patients. That being said, I think the relationship between (some) doctors, insurers, drug manufacturers, and the government is all messed up and contributes to such behavior.

Quote:
Originally Posted by robby View Post
The bottom line is that the so-called step therapy, while marketed as a way to control costs, often ends up either denying or delaying care to patients, or forces patients off of long-term drug therapy. Also, while the underlying premise is that similar drugs are basically interchangeable, this is rarely the case, because not all drugs work the same way in different people, and this includes efficacy as well as side effects.
Not all step therapy is bad. It sometimes makes sense to try (and fail) low-risk drugs before high-risk drugs.

~Max
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Old 08-15-2019, 08:04 AM
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Step therapy might make sense for newly diagnosed issues/patients. But it makes zero sense for people who are on "maintenance" medications for chronic conditions. Robby's asthma example is a good one. I'm also a good example. I've had arthritis my whole life (juvenile rheumatoid for those who want clarification). Over my 50+ years I've tried or used nearly all the available arthritis medications - everything from over the counter aspirin and Alleve to inexpensive prescription NSAIDS to expensive new biologics. I'm currently taking Enbrel, one of the expensive biologics, and Alleve on an as-needed basis to control pain.

EVERY time my insurance plan changes - which it does often because of our highly stupid system of tying health insurance to employment* - I am forced to do the step therapy. Let me say this bluntly:

JUST BECAUSE I AM NEW TO THIS INSURANCE PLAN DOES NOT MEAN I AM NEWLY DIAGNOSED WITH THE CONDITION/DISEASE.

I yelled that in the off chance that any insurance people are lurking here, because they don't seem to get it. Or more realistically, I suppose it's because it's easier to treat everyone the same. Health care paint-by-numbers.

What harm does doing the step therapy cause me? I talked about this in other threads, so I'll keep it short here. It's been more than once where getting a new insurance plan caused me to have to go without my Enbrel for 6 or more weeks while my doctor's office fought with the insurance company and I fought with the bureaucracy of their irritating-as-shit specialty pharmacy. Because not only is there the step therapy requirement, but they also will NOT allow you to get certain medications anywhere other than THEIR specialty pharmacy. Let me rephrase this one also:

The insurance company dictates which pharmacy I can get my Enbrel prescription filled at.

Seriously. Try to fill it at the local Walgreens, CVS or grocery store pharmacy? They will YANK it away from them (informing you of this with a snail-mailed letter) and force you to send/transfer the rx to their specialty pharmacy. The bureaucracy starts to kick in when you don't know which location of that specialty pharmacy you need to contact or send the rx to. You have to contact their prescription management program (ExpressScripts or CVS Caremark are well-known ones), and then THEY will start processing your rx and then tell you that the specialty pharmacy will contact you. It's very close to "don't call us, we'll call you".

I'm ranting at this point because it's such a hot button for me, so I'll stop. Just want to add the thing I footnoted above about my insurance changing so much: I don't change employers a lot. But between a few job changes and my employer changing plans, my insurance does get changed frequently.
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Old 08-15-2019, 09:23 AM
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Originally Posted by JcWoman View Post
EVERY time my insurance plan changes - which it does often because of our highly stupid system of tying health insurance to employment* - I am forced to do the step therapy...

It's been more than once where getting a new insurance plan caused me to have to go without my Enbrel for 6 or more weeks while my doctor's office fought with the insurance company and I fought with the bureaucracy of their irritating-as-shit specialty pharmacy.
In my experience, if you the patient go out of your way to understand the authorization process and call every day, you can get your drug fast-tracked. Get the doctor's office on your side, too. Phone calls are faster than snail mail and sometimes they fax the doctor's office too. Make sure your insurance company gets the full list of previous treatments you have tried for your condition, including start and stop dates. You can also take advantage of the thirty-day grace period after switching insurance plans, during which time they are required to cover your current prescription medicines. Use that time to work on getting exceptions to the formulary and authorization for your specialty medications. I would even request an exception to their step-therapy policy (you can do that). You will have to fill out paper forms, keep a list of stupid numbers and codes, and spend a lot of time on hold. Don't be mean, but remember that your health is more important than their "policies" and a gap in treatment is unacceptable.

Ideally you would never have to deal with any of this, but that's life.

ETA: You also have "friends" in the drug manufacturer. Call their patient line and they undoubtedly have a team of people whose only job is to guide doctors and patients through the insurance process.

~Max

Last edited by Max S.; 08-15-2019 at 09:28 AM.
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Old 08-15-2019, 10:45 AM
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Ideally you would never have to deal with any of this, but that's life.
Incorrect. That's the United States. That does NOT happen in other nations. It is not an inevitable part of life, it's evidence that the American health care system is jacked up.
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Old 08-15-2019, 12:37 PM
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In my experience, if you the patient go out of your way to understand the authorization process and call every day, you can get your drug fast-tracked. Get the doctor's office on your side, too. Phone calls are faster than snail mail and sometimes they fax the doctor's office too. Make sure your insurance company gets the full list of previous treatments you have tried for your condition, including start and stop dates. You can also take advantage of the thirty-day grace period after switching insurance plans, during which time they are required to cover your current prescription medicines. Use that time to work on getting exceptions to the formulary and authorization for your specialty medications. I would even request an exception to their step-therapy policy (you can do that). You will have to fill out paper forms, keep a list of stupid numbers and codes, and spend a lot of time on hold. Don't be mean, but remember that your health is more important than their "policies" and a gap in treatment is unacceptable.

Ideally you would never have to deal with any of this, but that's life.

ETA: You also have "friends" in the drug manufacturer. Call their patient line and they undoubtedly have a team of people whose only job is to guide doctors and patients through the insurance process.

~Max
I'm sorry, Max, but none of this has EVER worked for me. What, did you think I was just crying on my couch for 6+ weeks waiting for something to happen?

Hell yeah, I was on the phone every day. And the Enbrel support line does not help you work through the bureaucracy. All they do is give you a debit card to help pay the copays. (Which is valuable, but not until you actually are allowed to schedule shipment of your drug.) That's what they told me on the phone. I questioned them directly on this because you're not the first person who's told me that drug support lines help you work the system. They specifically answered that ALL they could do for me was help pay for the copays.

There's a reason I'm so salty about this. It's because even educating myself and being assertive, I could not break through the series of "fuck you, you'll get the drug if and when we feel like sending it you" messages I got. (Hmm, I should check if this thread is in the Pit, and if not stop replying because I can't seem to talk about it without f-bombs.)
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Old 08-15-2019, 01:00 PM
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We're not in the Pit, so I apologize for the language and will try not to do it again. But I want to outline my last 6+ week experience with doing exactly what you describe:

(Pharmacy management plan) PMP: "We don't have your prescription yet, give us your doctor's fax number and we'll get it" (The insurance company told me they yanked it away from the local pharmacy and sent it to the PMP. But apparently their process is that this just alerts them to the fact that I need to have an rx filled. It's still on me to have my doctor send ANOTHER copy of the rx to the PMP.)

Pharmacy: "We don't have your rx yet, the PMP hasn't sent it over yet" (days of this)

PMP: "We're checking with your insurance to see if this drug is covered by your plan" (days of this)

PMP: "Okay, your insurance covers this, but they require a Pre-Authorization. We sent our PA form to your doctor but they haven't sent it back. You should call them and tell them to get cracking"

Doctor: "We filled out the form and faxed it back yesterday"

PMP: "We haven't got it back yet"

Doctor: "We did send it! We'll send it again"

PMP: "We still don't have it." (When I told them that the doctor sent it to them twice, the piece of crap on the phone actually told me that my doctor is a liar. I'm not kidding you, she said that.)

Doctor: "We sent it twice, argh. I'll call them to find out what's up."

Next day doctor proactively calls ME: "Turns out they didn't like something we wrote on the form but instead of calling to ask about it, they were just sitting on it. We fixed it and faxed it again yesterday"

PMP: "We got the form from your doctor and it looks good. We're processing it"

PMP: "we're working on it"

PMP: "we're working on it"

me: "now that you have the PA, is there any way you can expedite this?"

PMP: "our process is our process, there's nothing I can do"

PMP: "we're working on it"

Pharm: "hi, we have your rx and are processing it. we'll call you soon to schedule shipping"

pharm: "we're still processing it. We'll call you when we can schedule shipping"

pharm: "we're still processing it. We'll call you when we can schedule shipping"

pharm: "we're still processing it. We'll call you when we can schedule shipping"

pharm: "we can ship it to you now. How does next Tuesday sound?"
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Old 08-15-2019, 01:13 PM
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This is misleading. Nobody is preventing doctors from prescribing nonformulary medicine without first exhausting formulary alternatives. It is your insurance company which refuses to pay for the medicine, therefore the pharmacy refuses to dispense. If you are willing to pay for the medicine, you can call your doctor and ask them to prescribe the nonformulary medicine. The doctor may refuse on medical grounds, though - they don't have to (and shouldn't) prescribe anything that isn't medically justified.
My doctors have no problem prescribing non-formulary medication; they have done so many times. The problem is that the insurance company is refusing to pay for them until and unless their preferred medications are tried and failed first, whether the doctor agrees with this approach or not.

One issue with paying out of pocket for medication is that the prices are jacked up (like many other medical costs). The list price for 45 grams of generic Westcort (hydrocortisone valerate cream, 0.2%) is apparently $180, which is insane. I don't think anyone actually pays this, though, because my insurance company offered me a GoodRx coupon to bring the price down to $56, and I'm sure they pay even less.

Incidentally, this is a drug that has been on the market at least as early as 1992 (27 years) under the brand name Westcort. The original manufacturer (Westwood Squibb) stopped marketing in over a decade ago (in 2006), and it is now only available as a generic, and has been available in generic form since 1998. I have no idea why this generic drug that has been on the market for decades would have a list price of more than $180 for a 45 gram tube of cream.

My insurerer's preferred medications are apparently Mometasone and Triamcinolone. Both of these have also been around for quite a while. The reason that they appear to be preferred is because they are considerably cheaper. However, both are also more potent corticosteroids that a doctor might not want to go to right away.

Mometasone furoate 0.1% is a Class 3—upper-mid-strength) corticosteroid; triamcinolone acetonide 0.1% is Class 4/Class 5; while hydrocortisone valerate cream, 0.2% is Class 5—lower mid-strength.

Anyway, it's hard enough for a physician to prescribe the best drug for their patient without also worrying about whether or not a patient's insurance will cover their preferred drug -- especially when it is a relatively common drug that has been on the market for decades. This is especially true for an acute problem, which is why a patient goes into an urgent care clinic in the first place. And if a patient finds out a prescribed drug is not covered, they have no recourse other than pay for the drug out-of-pocket or go back to the doctor for another prescription (which is a waste of time, money, and resources), and which delays treatment.

Quote:
Originally Posted by Max S. View Post
Not all step therapy is bad. It sometimes makes sense to try (and fail) low-risk drugs before high-risk drugs.

~Max
True enough. The problem is that health insurers are extending this to many, if not most, drugs regardless of risk. In many cases, they are demanding that patients try (and fail) higher-risk drugs first.

For example, the preferred corticosteroids in my insurer's formulary are both in a stronger class than the drug my doctor wanted to prescribe.

For another example, I had to fight with my insurer last year to get them to cover Skelaxin for back pain, a muscle relaxant with no noticeable side effects for me. Instead, they wanted me to take Flexeril, which makes me pass out and has a much stronger potential for drug dependency.
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Old 08-15-2019, 01:17 PM
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Sorry, I just thought of one more detail, which might explain my anger over this topic. A couple of the times I was calling the pharmacy I actually told them the reason I might be sounding terse was because I was overdue for taking my next dose by 3 weeks.... 4 weeks... The best they could do was a weak verbal shrug, because of course the clerks on the phone don't have the authority to bypass any of their process steps.

The icing on the cake was when I was finally able to schedule shipment. One of their standard questions is "when are you due for your next dose?". On this occasion I dryly (but not rudely) replied "6 weeks ago". Without missing a beat they go on to the next question, which makes me wonder why they even ask that. A few minutes later in the call they said "I need to verify your info so that you don't miss any doses" . Verifying the info is also standard, but I was astonished at how callous she was with that comment. Likely on a script autopilot, but the fact that my "6 weeks ago" reply was completely forgotten seemed to add insult to injury.

Again, I know she couldn't personally do anything about it. But a teaspoon of sensitivity to their customers wouldn't be amiss.
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Old 08-15-2019, 01:29 PM
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For starters, drug pricing is arbitrary and set by what the market will bear. Why does one drug cost $30 a month and another drug cost $3000 a month, anyway? It usually has nothing to do with the actual cost to develop and produce the drug by the manufacturer, or how long it has been on the market, and everything to do with what the pharmaceutical companies can get away with charging for it.
I am confused... you seem to think that somehow drugs are unique in that? EVERYTHING out there is priced like that- the only real relation they have to the cost of the item is that generally speaking, that's the lowest you can price the drug- any lower and you lose money.

Otherwise, there's no actual relationship between what it costs to produce/distribute/sell an item and the amount that it's actually priced at. None. It's all about what the market will bear, which is set by markets coming to equilibrium.

Some items are what are called "price insensitive", meaning that people buy them independent of raises in price/decreases in price. Stuff like gasoline, drugs, and other necessities all can fall in this category at various times, depending on supply, demand and substitutes. Other items are "price sensitive" meaning that the amount purchased is closely related to the price that's charged and the presence of substitutes.

Most items aren't price insensitive- you have options- "substitutes", or even the option of just not getting it at all. Candy bars are a good example. If they price the Snickers too high, you may choose a Baby Ruth, Kit Kat or Life Savers. Or you may go buy a cookie. Or just not get any sweets at all.

The prices are set by that equilibrium I spoke of earlier- the price of that Snickers bar will generally be in the same price band as other candy bars of similar size- one that's too high won't be bought, and ones that are too low are just leaving money on the table. It sounds like a good idea to undercut the others, but that generally just turns into a "race for the bottom" where all the producers trying to be the lowest price option continually undercut each other until they're just a tiny hair above their cost. Which is fine if you have costs that are even lower- you can undercut them just a hair and still make money. That's how Wal-Mart works.

Most items work on the idea that it's better to differentiate yourself in some way, and therefore try and justify a higher price in the mind of the consumer.

Of course drugs are a weird beast, because insurance and prescription regulations distort a lot of the mechanisms that would let prices come to equilibrium.
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Old 08-15-2019, 02:01 PM
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I am confused... you seem to think that somehow drugs are unique in that? EVERYTHING out there is priced like that- the only real relation they have to the cost of the item is that generally speaking, that's the lowest you can price the drug- any lower and you lose money.

Otherwise, there's no actual relationship between what it costs to produce/distribute/sell an item and the amount that it's actually priced at. None. It's all about what the market will bear, which is set by markets coming to equilibrium.

Some items are what are called "price insensitive", meaning that people buy them independent of raises in price/decreases in price. Stuff like gasoline, drugs, and other necessities all can fall in this category at various times, depending on supply, demand and substitutes. Other items are "price sensitive" meaning that the amount purchased is closely related to the price that's charged and the presence of substitutes.

Most items aren't price insensitive- you have options- "substitutes", or even the option of just not getting it at all. Candy bars are a good example. If they price the Snickers too high, you may choose a Baby Ruth, Kit Kat or Life Savers. Or you may go buy a cookie. Or just not get any sweets at all.

The prices are set by that equilibrium I spoke of earlier- the price of that Snickers bar will generally be in the same price band as other candy bars of similar size- one that's too high won't be bought, and ones that are too low are just leaving money on the table. It sounds like a good idea to undercut the others, but that generally just turns into a "race for the bottom" where all the producers trying to be the lowest price option continually undercut each other until they're just a tiny hair above their cost. Which is fine if you have costs that are even lower- you can undercut them just a hair and still make money. That's how Wal-Mart works.

Most items work on the idea that it's better to differentiate yourself in some way, and therefore try and justify a higher price in the mind of the consumer.

Of course drugs are a weird beast, because insurance and prescription regulations distort a lot of the mechanisms that would let prices come to equilibrium.
You wrote a whole lot here about markets and comparing drug prices to those of candy bars, before finally ending with: "Of course drugs are a weird beast, because insurance and prescription regulations distort a lot of the mechanisms that would let prices come to equilibrium."

That is exactly the point. The market for drug prices, like that of the entire healthcare industry, is completely distorted to the point that the normal price responses to supply and demand do not really apply like they do in the undistorted market of candy bars.

Even the part about price sensitivity does not really apply, because after a week of fighting with my insurer, the price for the non-preferred generic Westcort ended up costing me $5, just like the other two insurer-preferred medications.

But even were that not the case, the person choosing the medication (my doctor) is not the one paying for it. For that matter, neither the doctor nor the patient (me) have any idea what the list price of the medication is, what my insurance company pays for it, or even what I will pay for it (unless I first look it up on my insurer's website). All of this makes it difficult for market forces to function.

Now granted, after the fact, when I pick the medication up at the pharmacy, the list price might be listed on the paperwork, but that usually results in a simple, "Huh -- good thing I have insurance."
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Old 08-15-2019, 02:40 PM
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You wrote a whole lot here about markets and comparing drug prices to those of candy bars, before finally ending with: "Of course drugs are a weird beast, because insurance and prescription regulations distort a lot of the mechanisms that would let prices come to equilibrium."

That is exactly the point. The market for drug prices, like that of the entire healthcare industry, is completely distorted to the point that the normal price responses to supply and demand do not really apply like they do in the undistorted market of candy bars.

Even the part about price sensitivity does not really apply, because after a week of fighting with my insurer, the price for the non-preferred generic Westcort ended up costing me $5, just like the other two insurer-preferred medications.

But even were that not the case, the person choosing the medication (my doctor) is not the one paying for it. For that matter, neither the doctor nor the patient (me) have any idea what the list price of the medication is, what my insurance company pays for it, or even what I will pay for it (unless I first look it up on my insurer's website). All of this makes it difficult for market forces to function.

Now granted, after the fact, when I pick the medication up at the pharmacy, the list price might be listed on the paperwork, but that usually results in a simple, "Huh -- good thing I have insurance."
You made it sound like there's some sort of well-known relationship between the cost of something and the price that's set for it, and drug companies were just charging what they could charge, which is somehow dirty pool.

Which isn't the case; everything works that way, more or less. What makes the drug price situation so weird is pretty much everything you say. Which are in effect market distortions, not necessarily some sort of nefariousness on the part of drug companies (although that IS the problem a good part of the time).
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Old 08-15-2019, 03:49 PM
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You made it sound like there's some sort of well-known relationship between the cost of something and the price that's set for it, and drug companies were just charging what they could charge, which is somehow dirty pool.

Which isn't the case; everything works that way, more or less. What makes the drug price situation so weird is pretty much everything you say. Which are in effect market distortions, not necessarily some sort of nefariousness on the part of drug companies (although that IS the problem a good part of the time).
I don't mean to make it sound as though there is a relationship between the cost of something and the price that's set for it (other than possibly as a floor). With that said, I do think there is some kind of nefariousness going on with many drug companies, and I do think they are playing dirty pool.

In the undistorted market of candy bars, if Mars, Inc. raised the price of a Snickers bar to $180/each, its sales would likely go down to nearly zero -- which makes it very unlikely that Mars would ever do that.

But drug companies do this sort of thing all the time, and they seem to get away with it with impunity. I see no reason why two similar generic topical corticosteroids that have both been on the market for decades should differ in price by an order of magnitude. The normal market constraints that would punish that sort of behavior don't seem to be working.

One major difference is that people can easily forgo a candy bar, but can't always forgo a critical medication. To that can be added all the other market distortions and price opacity we have been discussing.

The consequence of all of this is needless human suffering, and not the kind of suffering like not getting a Snickers bar. Instead, it's things like a diabetic going without insulin.
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Old 08-15-2019, 04:02 PM
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I don't mean to make it sound as though there is a relationship between the cost of something and the price that's set for it (other than possibly as a floor). With that said, I do think there is some kind of nefariousness going on with many drug companies, and I do think they are playing dirty pool.

In the undistorted market of candy bars, if Mars, Inc. raised the price of a Snickers bar to $180/each, its sales would likely go down to nearly zero -- which makes it very unlikely that Mars would ever do that.

But drug companies do this sort of thing all the time, and they seem to get away with it with impunity. I see no reason why two similar generic topical corticosteroids that have both been on the market for decades should differ in price by an order of magnitude. The normal market constraints that would punish that sort of behavior don't seem to be working.

One major difference is that people can easily forgo a candy bar, but can't always forgo a critical medication. To that can be added all the other market distortions and price opacity we have been discussing.

The consequence of all of this is needless human suffering, and not the kind of suffering like not getting a Snickers bar. Instead, it's things like a diabetic going without insulin.
Oh, I agree. I'm pretty convinced it's the presence of insurance companies and their negotiated rates that distort everything, combined with undue greed on the part of the drug companies- it's like they stuck some recent MBA grad with no conscience in charge of pricing, and they realized suddenly that "Hey! Diabetics have to have insulin to live- we can charge astronomical prices because they have to pay!" without regard for how that looks or what that actually may mean.
  #15  
Old 08-15-2019, 04:09 PM
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Incorrect. That's the United States. That does NOT happen in other nations. It is not an inevitable part of life, it's evidence that the American health care system is jacked up.
Not entirely true. Canada does not have a national Pharma care program.

In Ontario, if you are poor or a senior or a child whose parents don’t have private insurance, you are covered under a some what limited formulary. Otherwise, you are on your own or have private coverage. Under my plan from work, the insurance company will push back on expensive biologics until you’ve tried conventional drugs first. I’ve never had pushback nor have any of my staff, as far as I know but I haven’t had anyone need the really expensive MS or cancer drugs or similar.
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Old 08-15-2019, 04:23 PM
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Oh, I agree. I'm pretty convinced it's the presence of insurance companies and their negotiated rates that distort everything, combined with undue greed on the part of the drug companies- it's like they stuck some recent MBA grad with no conscience in charge of pricing, and they realized suddenly that "Hey! Diabetics have to have insulin to live- we can charge astronomical prices because they have to pay!" without regard for how that looks or what that actually may mean.
Now that you mention this, it is rather fascinating. There's been a lot of pressure on the insurance companies to stop paying high prices for things like drugs. So they implemented the pharmacy management plans/companies that I referenced earlier. The fascinating thing is that this has utterly failed to bring downward pressure on drug prices. Even when people die and the media gets a hold of it like the poor diabetic man who died recently because he couldn't get insulin... even THAT doesn't seem to be stopping the drug price inflation.
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Old 08-15-2019, 06:58 PM
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We're not in the Pit, so I apologize for the language and will try not to do it again. But I want to outline my last 6+ week experience with doing exactly what you describe:
Except for the part where it takes days to receive faxes, that's what I had in mind. I try and give patients a copy of the fax confirmation so they have a timestamp and recipient number to help "locate" the fax. Other than that, what can I say? The system sucks.

And I'm surprised to hear that Enbrel sucks, too. All of our specialty medication manufacturers have dedicated patient advocacy teams who will, for free, take our prescription and fight the insurers on our (the doctor's office) behalf. I found a small paper from Amgen that like, defines patient advocacy, but doesn't give phone numbers or look helpful in any way shape or form. It would be a different department than cost assistance though. https://www.amgen.com/~/media/amgen/...ies.ashx?la=en

~Max
  #18  
Old 08-16-2019, 07:42 AM
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That's interesting that they have advocacy, even if it is apparently super secret. Even the cost advocacy people didn't seem to know about it because they were like "sorry, can't help you, don't know what to say". I don't blame them, just the system.

Completely tangentially, my Enbrel on past insurance plans has had a $50-$60 copay so I didn't really need copay assistance. But my current plan apparently really, REALLY wants me off it because they set the copay at $300. Guess who's actually paying that though? Enbrel Assist. (Actually, yes, we all are because the cost of the copay assistance programs are paid from the overall high cost of the drug itself. It's a nasty, incestuous system.)
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Old 08-16-2019, 08:10 AM
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Now that you mention this, it is rather fascinating. There's been a lot of pressure on the insurance companies to stop paying high prices for things like drugs. So they implemented the pharmacy management plans/companies that I referenced earlier. The fascinating thing is that this has utterly failed to bring downward pressure on drug prices. Even when people die and the media gets a hold of it like the poor diabetic man who died recently because he couldn't get insulin... even THAT doesn't seem to be stopping the drug price inflation.
The part that really stuns me, as a business school grad, is that the companies are going about this so blatantly. I mean, they could have basically done the price increases boiling-frog style at increases of $2-5 (or some other nominal amount) at a time over a period of time, and probably not attracted much attention.

But no, they somehow got the idea that it was a good idea to just jack up the prices in one fell swoop. It's like they didn't do any of their analyses that would have indicated that a bunch of negative media attention and public backlash might actually end up causing some sort of regulation on this sort of thing.

I suspect that'll be what happens in the end- there will be some sort of legislation passed that identifies some relatively small set of "critical" drugs and that'll place restrictions on price increases without corresponding cost increases, but that'll also allow for some adequate amount of profit and some sort of indexed price increase scheme. Maybe even with some sort of pricing guidelines (i.e. it's a generic, so it should be within a certain price band based on drug category type thing), or possibly something along the lines of subsidies.
  #20  
Old 08-19-2019, 05:03 PM
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This is misleading. Nobody is preventing doctors from prescribing nonformulary medicine without first exhausting formulary alternatives. It is your insurance company which refuses to pay for the medicine, therefore the pharmacy refuses to dispense. If you are willing to pay for the medicine, you can call your doctor and ask them to prescribe the nonformulary medicine. The doctor may refuse on medical grounds, though - they don't have to (and shouldn't) prescribe anything that isn't medically justified.
...
One problem, though, is that the formulary can change quite arbitrarily.

I vented here some years back about a forced switch to another preventative inhaler. I had been using Flovent for years.

Suddenly, it wasn't on the formulary. I had to switch (one of the options, interestingly, was a **more** expensive steroid + LABA that included fluticasone).

Doc shrugged, gave me a scrip for Symbicort - which is also a steroid + LABA.

And 6 months later, after 2 blood tests that showed my blood sugar creeping up despite a increase in exercise and some weight loss, I realized the timing was **just after I switched to Symbicort**.

And during this time, the insurer had quietly re-added Flovent to the formulary - with no notice.

I use a wakefulness-promoting medication. I switch between Nuvigil and Provigil (generics, both) depending on which one the insurance will pay for at any given time. Back when Nuvigil was brand-name-only, the insurance only paid for that (not the much cheaper Provigil).

In general, I have zero issue with using the cheaper option as the first try - but the rules are random, ever-changing, and utterly devoid of any common sense.
  #21  
Old 08-19-2019, 05:47 PM
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Originally Posted by JcWoman View Post
Now that you mention this, it is rather fascinating. There's been a lot of pressure on the insurance companies to stop paying high prices for things like drugs. So they implemented the pharmacy management plans/companies that I referenced earlier. The fascinating thing is that this has utterly failed to bring downward pressure on drug prices. Even when people die and the media gets a hold of it like the poor diabetic man who died recently because he couldn't get insulin... even THAT doesn't seem to be stopping the drug price inflation.
PBMs don't try to save the consumer (or the insurer) money.

They push the medications that give the biggest rebate. These rebates are not always passed on to the insurers, either.
https://www.statnews.com/2018/08/27/...s-good-or-bad/

https://en.wikipedia.org/wiki/Pharma...fit_management

All in all, it's a scam that helps to obfuscate the true cost of medications.

http://www.milliman.com/insight/2018...ducing-prices/
  #22  
Old 08-21-2019, 12:36 PM
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One problem, though, is that the formulary can change quite arbitrarily.
It doesn't make sense, and is often annoying. Still, and this is legally important but usually impractical, you can pay for the drug yourself, and the doctor can prescribe whatever he or she thinks is appropriate. Your insurance company only controls what they will pay for. They can say "we aren't paying for Flovent any more" but they can't stop the doctor from writing "Flovent" on the prescription pad. I think Flovent is $250-$300 a pop, and if you front the money, your drug plan will sit back and say "good for you". In practice, people can afford their health insurance, not health insurance plus the full price of prescription drugs.

~Max
  #23  
Old 08-21-2019, 12:47 PM
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The part that really stuns me, as a business school grad, is that the companies are going about this so blatantly. I mean, they could have basically done the price increases boiling-frog style at increases of $2-5 (or some other nominal amount) at a time over a period of time, and probably not attracted much attention.

But no, they somehow got the idea that it was a good idea to just jack up the prices in one fell swoop. It's like they didn't do any of their analyses that would have indicated that a bunch of negative media attention and public backlash might actually end up causing some sort of regulation on this sort of thing.
Two words: inelastic demand. Drug manufacturers don't care because they don't have to care. People will die without their drugs. You cannot boycott life-saving medications. Often enough, patents, insurance contracting, market forces, and simple biology will lock a patient in to a particular brand of medicine. These companies have only two sources of downward pressure: government regulation and the natural limit of how much people are willing to pay before they literally give up and die.

As it so happens, the government has a strong interest in making sure this second option is never exercised, and so it subsidizes a big chunk of prescription drugs. This leaves only one downward pressure, which is government regulation. It is no wonder that drug companies spend so much on lobbying, or that they are so successful in doing so.

~Max
  #24  
Old 08-22-2019, 09:54 PM
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It doesn't make sense, and is often annoying. Still, and this is legally important but usually impractical, you can pay for the drug yourself, and the doctor can prescribe whatever he or she thinks is appropriate. Your insurance company only controls what they will pay for. They can say "we aren't paying for Flovent any more" but they can't stop the doctor from writing "Flovent" on the prescription pad. I think Flovent is $250-$300 a pop, and if you front the money, your drug plan will sit back and say "good for you". In practice, people can afford their health insurance, not health insurance plus the full price of prescription drugs.

~Max
Yep.

There's usually an appeals process, if you can prove you tried the alternatives and they didn't work for whatever reason, but that can lead to delays. In my case if this happened again, I could argue that one switch caused problems in the past, but they might still argue.

I'm on a proton pump inhibitor - one of the newest ones on the market. Doc put me on that after it was clear an older version wasn't doing the job. He sent a letter to the insurer - and all was fine. This, I think, is a good example of the step process working as it should.

I use Metformin - the extended release version. Doc wanted to raise the dosage from 500 to 1,000 mg a day. 500 mg a day is very, very cheap. The 1,000 mg tablet was not covered - and if I could get it covered under appeal. it would have been CONSIDERABLY more expensive. It wasn't even a brand name, as I recall. Between Dropped-em not getting paperwork to the doctor, and/or the doctor not receiving the paperwork. and/or the doctor not *returning* the paperwork to Dropped-em, it was a full month before the appeal got filed and ultimately approved. Of course the doctor's office is partly culpable here too: I kept leaving messages saying "Well, why not just prescribe TWO 500MG TABLETS A DAY", and they kept not responding to that. They finally did - and that's what I use. Hella cheaper than the exact dosage in a single tablet.
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